• Obsessive-compulsive disorders are defined by repetitive thoughts and behaviours that are so extreme that they interfere with everyday life
  • Trauma-related: PTSD and acute stress disorder
  • Often experience other anxiety disorders alongside

Obsessive-Compulsive and Related Disorders

  • OCD defined by: repetitive thoughts and urges (obsessions) as well as an irresistible need to engage in repetitive behaviours or mental acts (compulsions)
  • Body dysmorphic and hoarding disorder share symptoms of repetitive thoughts and behaviours o BDD – preoccupation with imagined flaws in one’s appearance & excessive repetitive behaviours or acts regarding appearance
    • HD – acquisition of an excessive number of objects & inability to part with those objects
  • These syndromes often co-occur
  • 1/3 of those with body dysmorphic disorder meet criteria for OCD
  • ¼ of people with hoarding disorder meet criteria for OCD
  • 1/3 of people with OCD experience symptoms of hoarding

Clinical Descriptions of the OC and Related Disorders

  • All share repetitive thoughts and irresistible urge to engage repetitively in some behaviour/mental act
  • OCD:
    • = Based on the presence of obsessions or compulsions (most experience both) o Obsessions = intrusive and recurring thoughts, images or impulses that are persistent and uncontrollable and that often appear irrational to the person having them
    • Interfere with normal daily activities
    • Often involve fear of contamination from germs/disease
    • Compulsions = repetitive, clearly excessive behaviours or mental acts that the person feels driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some calamity from occurring
    • Feel compelled to repeat a ritual if feel as though did not execute it with precision o DO not regard pleasurable behaviours as compulsions (eating, drinking, gambling) o Tends to begin before age 10, fairly chronic o Pattern of symptoms appears to be similar across cultures o Prone to extreme doubts, procrastination, and indecision

Body Dysmorphic Disorder (BDD):

  • = Preoccupied with one or more imagined or exaggerated defects in their appearance
  • Women focus on their: skin, hair, facial features, breasts, hips, legs o Men focus on their: height, penis size, body hair
  • Find it very hard to stop thinking about these concerns (3-8 hours/day)
  • Compelled to engage in certain behaviours: checking appearance in mirror, comparing their appearance to other people, asking others for reassurance, using strategies to change their appearance/camouflage
  • 1/5 endure plastic surgery
  • 1/3 have suicidal ideation, 20% have attempted suicide o Avoid contact with others o Begins in adolescence
  • Social/cultural factors play a role in how people decide whether they are attractive o Women are more likely than men to report appearance dissatisfaction o Symptoms/outcomes are similar across cultures
  • Hoarding Disorder:
    • = Need to acquire is excessive, abhor parting with their objects even when others cannot say any potential value in them
    • Extremely attached to possessions, many collections of different categories of objects o Poor hygiene, exposure to dirt, difficulties cooking o ¾ engage in excessive buying and many are unable to work o 10% threatened with eviction o 1/3 also hoard animals (more often women than men) *view as animal rescuer o Usually begins in childhood or early adolescence
    • Animal hoarding doesn’t tend to emerge until middle age+

Prevalence and Comorbidity of the OC and Related Disorders

  • Lifetime prevalence: 2% for OCD and BDD, 1.5% for hoarding
  • OCD and BDD slightly more common among women, hoarding is equally common
  • Very few men seek treatment for hoarding
  • High rates of comorbidity
  • Often co-occur with anxiety and depression
  • OCD and BDD tend to co-occur with substance use disorders

Etiology of the Obsessive-Compulsive and Related Disorders

  • Moderate genetic contribution, heritability estimate of 40-50%
  • 3 closely related areas of the brain unusually active in people with OCD:
    • Orbitofrontal cortex = area of medial prefrontal cortex above the eyes o Caudate nucleus = part of basal ganglia o Anterior cingulate  Etiology of OCD:
    • Many of the disruptive thoughts and behaviours have adaptive value o Goal of CBT: understand why the person with OCD continues to show the behaviours/thoughts used to ward off an initial threat well after that threat is gone
      • OCD related to deficit in the intuitive sense of feeling security and closure
      • Yedasentience = subjective feeling of knowing that you have thought enough, cleaned enough, or in other ways done what you should to prevent chaos and danger from low-level threats in the environment ***biological deficit for OCD
      • Compulsions are reinforcing because they relieve the sensation

 

  • Thought Suppression:
    • People with OCD try harder to suppress their obsessions than other people and may actually make the situation worse  Feelings of responsibility for what occurs  Etiology of BDD:
  • People with BDD can accurately see and process their physical features
  • They are detailed oriented and this influences how they look at facial features, examine one feature at a time instead of examining the whole
  • Become engrossed in considering a small flaw
  • Consider attractiveness to be more important than others, self-worth is dependent upon it  Etiology of Hoarding Disorder:
  • Evolutionary perspective – would be adaptive to store any resources
  • Behavioural model: related to poor organizational abilities, unusual beliefs about possessions, and avoidance behaviours
  • Slow at sorting objects into categories, find it anxiety-provoking
  • Demonstrate an extreme emotional attachment to possessions *especially to animals
  • Avoidance (of anxiety from organizing clutter) helps maintain the clutter Treatment of the OC and Related Disorders  Medications:
  • Antidepressants most commonly used
  • Clomipramine used for OCD (50% reduction in symptoms) *youth and adults
  • Antidepressants more helpful than placebos for BDD *using clomipramine and fluoxetine

(continue to experience mild symptoms) o Hoarding symptoms respond less to medication treatment than other OCD symptoms  Psychological Treatment:

  • Exposure and response prevention (ERP) = exposure treatment to address compulsive rituals people with OCD use to ward off threats o OCD:
    • Hold belief that compulsive behaviours will prevent awful things from happening
    • ERP – exposure themselves to situations that elicit the compulsive act and refrain form performing the compulsive ritual
  • Not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus
  • The exposure promotes the extinction of the conditioned response (the anxiety)
    • Uses exposure hierarchy, highly effective *more than clomipramine
    • 25% of clients refuse ERP treatment
    • Cognitive – challenging beliefs about what will happen if one doesn’t engage in rituals, also use exposure to test beliefs o BDD:
    • ERP – exposure to feared activity e.g. interact with people who could be critical of their looks, response prevention  avoid looking in the mirror
    • Supplemented with strategies to address cognitive features o Hoarding Disorder:
    • Adaptation of ERP – focuses on getting rid of objects
    • Response prevention – halting the rituals engage in to reduce anxiety e.g. counting or sorting possession
    • Facilitate insight as to why this is a problem
    • Build family rapport
  • Deep Brain Stimulation: A Treatment in Development for OCD:
    • Involves implanting electrodes into the brain for those with chronic OCD that fails to respond after multiple pharmacological treatments
    • Implanted into nucleus accumbens or region at the margin of the ventral striatum o 50% attaint significant relief within a couple of month *still experimental

Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)

  • Diagnosed only when a person develops symptoms after a traumatic event
  • Horrific life experiences can trigger serious psychological symptoms

Clinical Description and Epidemiology of PTSD and ASD

  • PTSD = an extreme response to a severe stressor, including recurrent memories of the trauma, avoidance of stimuli associated with the trauma, negative emotions and thoughts, and symptoms of increased arousal
  • Diagnosis was developed after the Vietnam War
  • Serious trauma = an event that involved actual or threatened death, serious injury, or sexual violation
  • Military trauma is most common for men, rape trauma for women (1/3 of female rape victims meet criteria)
    • 70% of rapes are committed by someone known to the woman
  • In addition to exposure to trauma, diagnosis of PTSD requires a set of symptoms be present

1) Intrusively re-experiencing the traumatic event (1) (dreams/nightmares, memories, flashbacks)

2) Avoidance of stimuli associated with the event (1) *avoidance usually fails

Avoid internal or external reminders o 3) Other signs of negative mood and thought that developed after the trauma (2) *feeling detached from friends/family

4) Symptoms of increased arousal and reactivity (2) – continuously on guard, monitoring environment for danger, irritability, sleep disturbance

5) Symptoms began or worsened after the trauma and continued for at least 1 month o 6) Among children younger than 7, diagnosis requires only 1 symptom from each category

  • Symptoms may develop soon after trauma or not until years after
  • Symptoms are relatively chronic
  • Suicidal thoughts are common, so is non-suicidal self-injury
  • Prolonged exposure to trauma might lead to a broader range of symptoms = complex PTSD
  • ASD = diagnosed when symptoms occur after a trauma, symptoms are fairly similar to PTSD but the duration is shorter o Only applicable when symptoms last for 3 days to 1 month
    • 1) Diagnosis could stigmatize short-term reactions to serious traumas, even though they are quite common
    • 2) Most people who go on to meet diagnostic criteria for PTSD do not experience DSM-IV-TR diagnoses of ASD in the first month after the trauma
    • Elevated risk of developing PTSD within 2 years
  • PTSD is highly comorbid with other conditions: anxiety, depression, substance abuse, conduct disorder
  • Women are 2x as likely to develop PTSD after trauma then men
  • Some cultural groups are exposed to higher rates of trauma (e.g. minority populations in US)

Etiology of PTSD

  • 2/3 of people with PTSD have a history of an anxiety disorder
  • PTSD related to genetic risk for anxiety disorders *high activity in fear circuit areas (amygdala), childhood trauma, tendencies to attend selectively to cues of threat
  • Neuroticism and negative affectivity predict the onset of PTSD
  • Related to Mowrer’s 2-factor model of conditioning (classical conditioning and operant conditioning)  Nature of the Trauma: Severity and the Type of Trauma Matter:
    • PTSD rates are doubled with soldiers who have a second tour of duty o More prisoners of war develop PTSD than those only wounded in war o Traumas caused by humans are more likely to cause PTSD than natural disasters  Neurobiology: The Hippocampus:
    • PTSD uniquely related to the function of the hippocampus o Hippocampus volume is smaller in those with PTSD
    • Smaller than average hippocampus volume precedes the onset of the disorder o Plays role in ability to locate autobiographical memories in space, time and context, and in organizing our narratives of those memories
    • Decreased hippocampus volume could explain deficit in verbal memory
  • Coping:
    • People who cope with trauma by trying to avoid thinking about it are more likely to develop

PTSD o Dissociation = feeling removed from one’s body or emotions or being unable to remember the event *may keep the person from confronting the event

  • Symptoms of dissociation after trauma are predictive of development of PTSD o High intelligence and strong social support may help cope with severe trauma more adaptively

Treatment of PTSD and ASD

  • Medication Treatment of PTSD:
    • SSRIs receive strong support as a treatment o Relapse is common if medication is discontinued
  • Psychological Treatment of PTSD:
    • Exposure treatment
    • Client is asked to face his worst fears, by working up an exposure hierarchy
    • Extinguish fear response or help challenge the idea that the person could not cope with anxiety/fear generated by those stimuli
    • Exposure focused on memories/reminders of trauma o In-vivo – returning to scene of the crime
      • Imaginal exposure = the person deliberately remembers the event o Virtual reality technology sometimes used o More effective that medication
    • Cognitive processing therapy  designed to help victims of rape and sexual abuse dispute tendencies towards self-blame  Psychological Treatment of ASD:
    • Short-term CBT include exposure therapy o Decreases chances of ASD developing into PTSD (reduced to 32% compared to 58%) o Exposure more effective than cognitive restructuring in preventing development of PTSD